Hinged multiperforator-based extended dorsalis pedis adipofascial flap for dorsal foot defects.

BACKGROUND: Adipofascial flaps covered with a skin graft address the challenges involved in reconstructing dorsal foot defects. The purpose of this study was to describe a large adipofascial flap based on the perforators of the dorsalis pedis artery for large foot defects. METHODS: Twelve patients aged 5-18 years with large soft tissue defects of the dorsal foot due to trauma were treated with an extended dorsalis pedis adipofascial flap from May 2016 to December 2018. The flap was elevated from the non-injured half of the dorsum of the foot. Its length was increased by fascial extension from the medial or lateral foot fascia to the plantar fascia to cover the defect. All perforators of the dorsalis pedis artery were preserved to increase flap viability. The dorsalis pedis artery and its branches were kept intact. RESULTS: The right foot was affected in 10 patients, and the left foot in two patients. All flaps survived, providing an adequate contour and durable coverage with a thin flap. Follow-up lasted up to 2 years, and patients were satisfied with the results. They were able to wear shoes. Donor-site morbidity was negligible. Two cases each of partial skin graft loss and superficial necrosis at the tip of the donor cutaneous flap occurred and were healed by a dressing. CONCLUSIONS: The hinged multiperforator-based extended dorsalis pedis adipofascial flap described herein is a suitable method for reconstructing dorsal foot defects, as it provides optimal functional and aesthetic outcomes with minimal donor site morbidity.

Anatomy of the dorsalis pedis artery / Anatomía de la arteria dorsal del pie

The dorsalis pedis artery (DPA) is the largest blood vessel distal to the ankle joint. It is the continuation of the anterior tibial artery (ATA) and runs along the dorsum of the foot until the 1st intermetatarsal space. The DPA gives rise to five branches, viz. medial tarsal, lateral tarsal, arcuate, deep plantar and dorsal metatarsal arteries. Given the vast blood supply provided by the DPA, in the current era of microvascular surgery, the anatomy of the DPA is of increasing interest to anatomists, surgeons and angiographers. The aim of this study was to outline the course, origin, branching patterns and possible variations of the DPA. The present study included the dissection of forty (n=40) cadaveric specimens of the lower limb region (Left: 25; Right: 15). The origin, course and branching patterns of the artery were studied. These morphological parameters were further analysed with regard to laterality to determine if a correlation existed. The Pearson Chi-square test was employed and a p value of less than 0.05 was deemed statistically significant. Although the DPA was present in 97.5 % of cases, it followed the standard anatomical description in only 42.5 % of cases. The DPA originated from the peroneal artery in 5 % of cases. In 25 % of cases, DPA deviated laterally. Variation in the branching pattern of the DPA, which was recorded in 50 % of cases, was further classified according Types 1 to 6. The findings of this study correlated closely with most previous studies. However, the incidence of lateral deviation of the DPA was higher in this study as well as the incidence of Type 1 variation in branching pattern. Additionally, this study proposes a novel variation in branching pattern which has been termed Type 6, which displays a recurrent branch of the Type 5 variation. The DPA has an important role in a clinical setting since the DPA flap is employed in reconstructive surgeries and peripheral circulation may be assessed by the palpation of the DPA pulse. Therefore, a thorough understanding of the anatomy of the DPA is of prime importance to podiatrists, surgeons, anatomists and angiographers.

La arteria dorsal del pie (ADP) es el vaso sanguíneo más grande distal a la articulación del tobillo. Es la continuación de la arteria tibial anterior (ATA) y se extiende a lo largo del dorso del pie hasta el primer espacio metatarsiano. La ADP da lugar a cinco ramas: a. tarsalis medialis, a. tarsalis lateralis, a. arcuata, a. plantaris profunda y aa. metatarsales dorsales. Dado el vasto suministro de sangre proporcionado por la ADP, en la era actual de la cirugía microvascular, la anatomía de la ADP es de creciente interés para los anatomistas, cirujanos y expertos en angiografía. El objetivo de este estudio fue delinear el curso, origen, patrones de ramificación y las posibles variaciones de la ADP. El presente estudio incluyó la disección de cuarenta (n = 40) muestras cadavéricas del miembro inferior (izquierda: 25; derecha: 15). Se estudiaron los patrones de origen, curso y ramificación de la arteria. Estos parámetros morfológicos se analizaron adicionalmente con respecto a la lateralidad para determinar si existía una correlación. Se empleó la prueba Chi-cuadrado de Pearson y se consideró estadísticamente significativo un valor de p de menos de 0,05. Aunque la ADP estuvo presente en el 97,5 % de los casos, siguió la descripción anatómica estándar en solo el 42,5 % de los casos. La ADP se originó en la arteria fibular en el 5 % de los casos. En el 25 % de los casos, la ADP se desvió lateralmente. La variación en el patrón de ramificación de la ADP, que se registró en el 50 % de los casos, se clasificó según los tipos 1 a 6. Los hallazgos de este estudio se correlacionaron estrechamente con la mayoría de los estudios previos. Sin embargo, la incidencia de desviación lateral de la ADP fue mayor en este estudio, así como la incidencia de la variación del tipo 1 en el patrón de ramificación. Además, este estudio propone una nueva variación en el patrón de ramificación que se ha denominado Tipo 6, que muestra una rama recurrente de la variación Tipo 5. La ADP tiene un papel importante en la clínica, ya que el colgajo de la ADP se emplea en cirugías reconstructivas y la circulación periférica se puede evaluar mediante la palpación del pulso de la ADP. Por lo tanto, una comprensión profunda de la anatomía de la ADP es de vital importancia para los podólogos, cirujanos, anatomistas y en la angiografía.

Repairment of skin defects of penetrating palm wound by application of free string-type dorsalis pedis flap and anterior malleolus flap / 中华显微外科杂志

Objective To investigate the clinical outcome of the feasible method of the free string type dor salis pedis flap and anterior malleolus flap in the repairement of skin defects caused by penetrating wound of palm.Methods From May,2011 to January,2017,the anterior combined ankle flap of the ankle were used to repair skin defects of 16 cases who sutained penetrating wounds of palm.Results All 32 flaps in the 16 cases survived.Follow-up were done from 2 months to 2 years after operation.Bone healing was achieved in all cases.Two-point discrimination recovered to 6-8mm.Total active range of motion of the fingers reached 75 ％ of the normal side.Both appearance and texture of the flaps were good.Both the appearances of the repaired palms and the functional recovery were satisfactory.The function assessment of the hand was excellent in 8 cases,good in 5 cases,fine in 2 cases and poor in 1 case.The eligible rate was 81.25 ％.Conclusion The anatomy of the dorsalis pedis flap and anterior malleolus flap is rare variant,which facilitate the dissection of the flaps during operation.The repairement of skin defects at two sides,both the palm and the back of hand,can be achieved via one operation.Therefore,the free string type dorsalis pedis flap and anterior malleolus flaps offer an ideal procedure to repair skin defects secondary to penetrating wound of palm.

Simultaneous reconstruction of the oral commissure, lip and buccal mucosa with microvascular transfer of combined first-second toe web and dorsalis pedis flap.

The reconstruction of oral commissure, lip and mucosa defects following tumour resection is a challenging task to the reconstructive surgeon owing to the increasing aesthetic and functional demands. The authors describe a case in which the use of combined first-second toe web with dorsalis pedis flap was transferred and an optimal result was achieved for the oral commissure, lip and buccal mucosa following resection of squamous cell carcinoma and local flap failure.

Comparison of venous drainage in flow-through and conventional dorsalis pedis flaps for repair of dorsal foot defects.

Inadequate venous drainage can lead to congestion and necrosis of flaps used in the repair of defects, thereby elevating the risk of flap failure. In this study, we sought to test the hypothesis that the venous drainage was better in flow-through flaps than in conventional dorsalis pedis free flaps used in the repair of dorsal foot defects. In this retrospective study, we investigated the data of 14 patients who underwent repair with flow-through flaps (n = 7) or conventional flaps (n = 7) for dorsal foot defects, between January 2007 and December 2013. The defects ranged from 6.2 × 11 cm to 9.5 × 16 cm in size. The donor sites were resurfaced using full-thickness free-skin grafts, and after transfer, the flaps were evaluated for postoperative congestion, surviving area, and sensory function. The results showed that the operative time was significantly longer for flow-through flaps than for conventional flaps (6.4 ± 1.7 h vs. 4.3 ± 1.2 h, P = 0.020), mainly due to additional dissection of the first dorsal metatarsal artery required in the case of the former. Necrosis was observed in the case of 4 conventional flaps, but not in the case of flow-through flaps. The flow-through flaps showed significantly lower incidence of congestion and higher survival area proportion than the conventional flaps (P < 0.05). The flow-through dorsalis pedis flaps have the advantages of lower incidence of necrosis and congestion and better survival over the conventional flaps in the repair of dorsal foot defects, and absence of additional morbidities, but required a longer operative time than conventional flaps.

Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap.

BACKGROUND: Our aim was to summarize the treatment of degloving injury involving multiple fingers using combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap. PATIENTS AND METHODS: Each degloved finger was debrided under microscopic guidance and embedded in the superficial layer of the abdominal fascia. The abdominal skin was sutured to the skin on the back and side of the hand to promote circumferential healing. After removal, the only remaining injured region was on the flexor surface, and this was repaired by multiple dorsal toe flaps, toe-web flaps, and dorsalis pedis flaps to provide blood vessels and sensory nerves. All fingers had proper flap thickness 3-6 months after surgery, and required only lateral Z-plasty modification with web deepening and widening to narrow the fingers and extend their relative length. RESULTS: We completed flap-graft and finger narrowing for 25 fingers in eight patients. Abdominal skin flaps and dorsal toe flaps were grafted, and resulted in both firmness and softness, providing finger flexibility. The dorsal toe flap provided good blood circulation and sensory nerves, and was used to cover the finger-flexor surface to regain sensation and stability when holding objects. During the 1-8 years of follow-up, sensation on the finger-flexor side recovered to the S3-4 level, and patient satisfaction based on the Michigan Hand Outcomes Questionnaire was 4-5. Flap ulcers or bone/tendon necrosis were not observed. CONCLUSION: Treatment of degloving injury involving multiple fingers with combined abdominal superficial fascial flap, dorsalis pedis flap, dorsal toe flap, and toe-web flap was effective and reliable.

Serial reconstruction of anophthalmic orbits with 'bag-shaped' flaps.

BACKGROUND: The author's goal was to present an approach for serial surgical reconstruction of anophthalmic orbits with 'bag-shaped' flaps and cartilage transplantation. METHODS: A review was performed of 53 patients who underwent serial physiological orbital reconstruction between 2006 and 2013. Orbital reconstruction was performed serially in stages, including "bag-shaped" flap transplantation, medial and lateral canthoplasty, tarsus reconstruction, and improvement of the strength of the levator palpebrae superior muscles. Curative effects were evaluated by the surgeons and patients jointly. RESULTS: Among the total of 53 cases, the curative effects were assessed as excellent in 28 patients, good in 17 patients, moderate in 6 patients, and poor in 2 patients. Two cases suffered necrosis of the bag-shaped flap, which was remedied with a frontal island flap and skin grafting; 4 cases experienced shallowness of the lower fornix, of which three were remedied by deepening of the lower fornix and the other by lower eyelid suspension. The appearance of the reconstructed eye socket was acceptable, natural and persistent. CONCLUSION: This procedure offers staged and serial reconstruction of anophthalmic orbits, according to the orbital shape and the volume loss of the orbital soft tissue. It is an ideal approach to reconstruct eye sockets, with a high survival rate of the flaps, acceptable appearance of the reconstructed eye socket, and stable depth of the upper and lower eyelid fornices.

A Previously Discounted Flap Now Reconsidered: MatriDerm and Split-Thickness Skin Grafting for Tendon Cover Following Dorsalis Pedis Fasciocutaneous Flap in Lower Limb Trauma.

OBJECTIVE: The dorsalis pedis flap has reliable vascularity; however, its use is limited by reports of donor site morbidity including infection, delayed healing, exposure of tendons, and later contractures. The purpose of this study was to demonstrate its continued role in lower limb trauma when the donor site is reconstructed with MatriDerm to avoid complications. METHODS: A 65-year-old man presented with a displaced, Gustilo 3b open transverse fracture of his left distal fibula. He had a 2 cm(2) open wound over his lateral malleolus. RESULTS: Following review of possible local options, a dorsalis pedis fasciocutaneous flap was deemed best for coverage, and the donor site was closed with 1-mm MatriDerm dermal matrix and a 6/1000 inch split-thickness skin graft (STSG) in a single stage. Three months postoperatively, the foot had excellent function and cosmesis, with toes in a neutral position and a full range of movement. CONCLUSIONS: The dorsalis pedis flap is a valuable reconstructive option for defects of the foot and ankle. Its major limitation donor site morbidity can be overcome by the additional application of a dermal substitute such as MatriDerm under the STSG.

Repairment of skin defects secondary to penetrating wound of palm with the application of free string-type dorsalis pedis flap and anterior malleolus flap / 中华显微外科杂志

Objective To investigate the clinical outcome of the feasible method of the free string type dorsalis pedis flap and anterior malleolus flap in the repairement of skin defects caused by penetrating wound of palm. Methods From May 2004 to July 2009, the free string-type dorsalis pedis flap and anterior malleolus flap were used to repair skin defects of 16 cases who sutained penetrating wounds of palm.Results All 32 flaps in the 16 cases were all survived. Follow-ups were done from 6 months to 2 years after operation. Both the appearances of the repaired palms and the functional recovery were satisfactory. The function assessment of the hand was excellent in 8 cases, good in 5 cases, fine in 2 cases and poor in 1 case.The eligible rate was 81.25%. Conclusion The anatomy of the dorsalis pedis flap and anterior malleolus flap is rare variant, which facilitate the dissection of the flaps during operation. The repairement of skin defects at two sides, both the palm and the back of hand, can be achieved via one operation. Therefore, the free string type dorsalis pedis flap and anterior malleolus flaps offer an ideal procedure to repair skin defects secondary to penetrating wound of palm.

Cross-Leg Achilles Tendon Reconstruction Using a Composite Flap of Dorsalis Pedis and Tendon Strips of the Extensor Digitorum Longus in a Vascular Compromised Wound

Reconstructions of soft tissue defect of the posterior ankle including Achilles the tendon should take into account not only coverage but functional outcome. Various methods of tendon transfer and tendon graft have been reported as a single-stage procedure. With advances and refinements in microsurgical techniques, several free composite flaps including tendon, fascia, or nerve have been used in single-stage reconstructions of large defects in this area minimizing further damage to the traumatized leg. However, when free flap is not feasible for some reasons, this cannot be accomplished successfully. Here we present a patient with Achilles tendon and circumferential large soft tissue defect. Because of circulatory compromise of the lower extremity, free flap reconstruction could not be applied. Instead, cross-leg composite flap of the dorsalis pedis flap including the extensor hallucis brevis musle and tendon, and tendon strips of the Second, third and fourth extensor digitorum logus were employed, Functional reconstruction of the tendon and resurfacing were obtained at the same time. The flap was detached 3 weeks postoperatively, and the transplanted flap has survived without any complications. By 3 months after surgery, full weight bearing, tip-toe standing and even walking without crutch assistance was possible. When functional reconstruction with the free flap is unattainable in the large defect of the posterior ankle including the Achilles tendon, cross-leg composite island flap of dorsalis pedis flap and tendon strips of the extensor digitorum longus tendon is a viable alternative.

Treatment of Soft Tissue Defect after TKA Using Dorsalis Pedis Flap: A Case Report

Skin and soft tissue defect developed after total knee arthroplasty have important influence on prosthesis survival. Thus an adequate treatment have to be performed according to the size and depth of defect. We report a case of dorsalis pedis flap for treatment of skin and soft tissue defect combined with infection after conversion total knee arthroplasty and its good result with a review of the literature.

The Clinical Study of Free Dorsalis Pedis Flap by Microsurgery / 대한정형외과학회잡지

Free dorsalis pedis flap transfers were performed in twelve cases at the Department of Orthopaedic Surgery of Hanyang University Hospital from January, 1980 to December, 1983. The result were summerized as followings; 1. Among twelve cases of the free dorsalis pedis flap transfer, neurovascular flap transfers were performed in nine cases and tendocutaneous flap transfers in five cases. 2. In all cases the textures of flaps were improved and the bulky subcutaneous fat tissues were shrunk gradually, so cosmetically good results were obtained. 3. Temperature, pain, protective and touch sensations were retained or restored by preservation of sensory nerve. 4. Free dorsalis pedis flap transfer has many advantages compared to conventional skin grafts, such as shorter therapeutic time, lesser physical or economic demands and primary covering to vital organ. 5. In injured hands, the application of free dorsalis pedis flap transfer including long extensor tendons of foot has been shown the excellent clinical result in the point of functional and cosmetic effect in dorsum of hand, as transferring simultaneously free tendon and skin flap. 6. Free dolis pedis flap transfer needs abundant experiences, meticulous microvascular technique and anatomic knowledge.